A Contemporary 20-Year Cleveland Clinic Experience of Non-bacterial Thrombotic Endocarditis: Etiology, Echocardiographic imaging, Management, and Outcomes

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Am J Med. 2020 Aug 19:S0002-9343(20)30704-X. doi: 10.1016/j.amjmed.2020.06.047. Online ahead of print.


BACKGROUND: Non-bacterial thrombotic endocarditis, or marantic endocarditis, is rare. Contemporary data on the etiology, echocardiographic evaluation, and management of non-bacterial thrombotic endocarditis are limited.

METHODS: A single center retrospective cohort study was performed. Electronic medical records and echocardiographic records were searched for patients ≥18 years, with a confirmed diagnosis of non-bacterial thrombotic endocarditis between January 1999 and November 2019. Demographic, echocardiographic, and management data were collected.

RESULTS: Out of 600,577 transthoracic echocardiograms (TTEs) and 89,264 transesopahgeal echocardiograms (TEEs), 42 patients had non-bacterial thrombotic endocarditis (mean age: 54 ± 14.5 years; 66.7% were female). The median duration of follow-up was 8.2 (interquartile range (IQR): 3.3 - 24.4) months. Seventeen patients (40.5%) had malignancy, 33.3% had systemic lupus erythematosus, and 35.7% had antiphospholipid antibody syndrome. Stroke was the most common presentation (59.5%). TTE enabled the diagnosis in 19 cases (45.2%), compared with TEE which identified the condition in 33 out of 34 (97.1%) cases, in which it was utilized. Three-dimensional (3D) echocardiography was performed in 17 TEEs. The most common valves involved were mitral (61.9%), and aortic (23.8%) valves. Thirty-two patients were managed with anticoagulation. Ten patients underwent surgery. Sixteen (38.1%) patients died, most of whom had a diagnosis of advanced malignancy.

CONCLUSION: In a contemporary 20-year cohort, TTE and TEE played important roles in diagnosis, with superior diagnostic performance of TEE for non-bacterial thrombotic endocarditis. Mortality was high, and advanced malignancy portended a worse prognosis. Management in most cases was therapeutic anticoagulation. In select cases, surgery provided favorable outcomes.

PMID:32827467 | DOI:10.1016/j.amjmed.2020.06.047

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